Early therapy slows HIV progression in babies

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Very early treatment of babies infected with HIV—before age 3 months—is associated with better outcomes than when treatment is delayed, investigators report in this week’s Journal of the American Medical Association.

Dr. Yvonne A. Maldonado, at Stanford University School of Medicine and members of the California Pediatric HIV Study Group studied time trends in early progression of HIV infection among 205 children born between 1988 and 2001, using records of clinic visits through age 3.

About two-thirds of the children were given some form of antiretroviral therapy (ART). By age 3 years, 81 progressed to an advanced disease stage. Absence of treatment with ART was associated with increased risk of disease progression.

Among 23 children treated with three anti-HIV drugs, including either a drug called a protease inhibitor or another type called a nonnucleoside reverse transcriptase inhibitor, none progressed to the advanced stage.

The authors note that even ART with one or two drugs, if initiated by age 2 months versus 3 to 4 months, was associated with delayed and decreased progression to advanced stages.

“Because there are potential drawbacks of very early therapy...large, prospective clinical trials defining the differences between very early versus delayed institution of therapy are needed,” Maldonado’s group indicates.

These findings emphasize the need to test pregnant women for HIV to detect HIV-infected infants as soon as possible to maximize the benefits of early treatment, they add.

In a second study in the Journal, the likelihood of needing to switch therapy—suggestive of treatment failure—is far greater among children treated with regimens lacking protease inhibitors and those who begin ART at advanced disease stages.

Dr. Susan Brogly, at Harvard School of Public Health in Boston, and her team examined changes in the treatment of pediatric HIV infection in the US from 1987 to 2003. Included were 766 children.

“After the pediatric guidelines were published, nobody had looked at whether they are being followed in clinical practice,” Brogly told Reuters Health. Drug prescribing could be quite different compared with adult guidelines, she added, because of the unique needs of children.

The researchers observed that since the pediatric guidelines were released in 1998, 22 percent of HIV-infected children were started on a regimen not recommended by the guidelines. Of 753 patients who were treated with any ART, 606 children were switched to a second regimen.

“Once our results were adjusted for age and year of calendar start, we found that older regimens—those including one and two nucleoside reverse transcriptase inhibitors—were associated with shorter time to first regimen switch,” the researcher noted.

“We also identified that children who start therapy when they are severely immunosuppressed also had a shorter time to regimen switch,” she continued. This is important, she added, because “more exposure to more drug classes and specific drugs, the more it can lead to drug resistance if not taken properly. Switching could also result in a reduction of future treatment options.”

In a related editorial, Dr. Ram Yogev, at Children’s Memorial Hospital in Chicago, points out that “while it is possible to celebrate the tremendous change in the outcomes of HIV-infected children treated with (combinations of AIDS drugs), it is even more important to continue to prioritize research for the survivors who are now living with a chronic disease.”

SOURCE: Journal of the American Medical Association, May 11, 2005.

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